CID 1992:15 (July)
175
Correspondence
Pyogenic Sacroiliitis Due to Veillonella parvula
J. Pouchot, Ph. Vinceneux, C. Michon, A. Mathieu, and Y. Boussougant Service de Medecine Interne V. Universite Paris VII. HOpita! Louis Mourier. Colombes. France
References 1. Singh N. Yu VL. Osteomyelitis due to Veillonella parvula: case report and review. Clin Infect Dis 1992;14:361-3. 2. Raff MJ. Melo Jc. Anaerobic osteomyelitis. Medicine (Baltimore)
1978:57:83-103. 3. Ziment I. Davis A. Finegold SM. Joint infection by anaerobic bacteria: a case report and review of the literature. Arthritis Rheum
Correspondence: Dr. Jacques Pouchot, Service de Medecine Interne V, Hopital Louis Mourier, 178 rue des Renouillers, 9270 I Colombes Cedex, France.
Clinical Infectious Diseases 1992;15:175 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1501-0029$02.00
Group C Streptococci: A Current View SIR-A recent letter by Vance [l] addressing the review of group C streptococcal bacteremia by Bradley et al. [2] emphasized the need for physiological testing in addition to serological grouping for accurate identification of group C streptococci. This concept is certainly sound, but newer taxonomic information has enlarged the topic of group C streptococci to include group G streptococci and the recent reclassification of"Streptococcus milled" organisms. ,a-Hemolytic streptococci can usually be characterized as forming large or small colonies, with the large-colony formers comprising virulent group A, C, and G strains and the smallcolony formers (which may exhibit group A, C, G, or F anti-
Correspondence: Dr. Kathryn L. Ruoff. Microbiology Laboratories. Massachusetts General Hospital. Boston, Massachusetts 02114.
Clinical Infectious Diseases 1992;15:175-6 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/150[-0030$02.00
1969;12:627-35. 4. Longoria RR. Carpenter JL. Anaerobic pyogenic sacroiliitis. South Med J 1983;76:649-51. 5. Rosenberg D. Baskies AM. Deckers PJ. Leiter BE, Ordia Jl, Yablon IG. Pyogenic sacroiliitis. An absolute indication for computerized tomographic scanning. Clin Orthop 1984; 184:128-32.
gens) representing members of the "S. mil/err' group. The taxonomic study of Farrow and Collins [3] demonstrated that large-colony-forming group G isolates from humans and group C strains resembling "Streptococcus equisimilis" are physiologically and genetically similar enough to be included in the same species. These investigators proposed the name Streptococcus dysgalactiae (formerly used for a-hemolytic group C strains isolated from animals) for these organisms. Among strains commonly isolated from animals. those resembling "Streptococcus zooepidemicus" were considered to form a subspecies of Streptococcus equi. Devriese et al. [4] subsequently proposed Streptococcus canis as the official name for large-colony-forming ,a-hemolytic group G streptococci isolated from animals. Meanwhile, Whiley and Beighton [5] presented taxonomic evidence that the "S. millen', group organisms, formerly included in a single species (Streptococcus anginosus) by Coykendall and associates [6]. really consist of three separate species: Streptococcus constellatus, Streptococcus intermedius. and S. anginosus. According to their emended species descriptions [5] and other data provided by Whiley et al. [7], it seems that smallcolony-forming group C or G ,a-hemolytic strains could be classified as either S. anginosus or S. constellatus. Some of the princi-
Downloaded from http://cid.oxfordjournals.org/ at Sheffield University on September 15, 2015
SIR-We read with interest the recent report and review by Singh and Yu [I] on osteomyelitis due to Veillonella parvula. They emphasized the rarity of bone infection due to anaerobic bacteria. We would like to report a unique case of septic sacroiliitis due to V. parvula. A 33-year-old alcoholic man presented with an 8-day history of excruciating low back and right buttock pain associated with a fever of 38.5°C. The patient was unable to bear weight; physical examination revealed tenderness over the sacroiliac joint, and the conventional maneuvers to stress the sacroiliac joint were painful. There was no palpable abscess, and the remainder of the physical examination was unremarkable. An initial pelvic radiograph was considered normal. High clinical suspicion of infectious sacroiliitis led to the performance of a bone scan, which revealed increased uptake over the right sacroiliac joint. The computed tomographic examination showed joint space widening with bony erosions of both iliac and sacral joint margins. There was no evidence of abscess in the surrounding soft tissues. The erythrocyte sedimentation rate (ESR) was 101 mm/ h, and the white blood cell (WBC) count was 11,500/mm 3 • Needle biopsy of the right sacroiliac joint was performed, which disclosed evidence of infectious sacroiliitis with inflammatory changes associated with numerous altered polymorphonuclear neutrophils. Unfortunately, the biopsy was performed after the patient had received 6 million units of penicillin G, and culture
of bone samples remained sterile. Three blood cultures yielded V. parvula that was susceptible to penicillins, cephalosporins, clindarnycin, and chloramphenicol. Therapy consisted of bed rest and administration of intravenous penicillin G (24 million units per day) for the first 2 weeks. Oral amoxicillin (3 g per day) was administered for the subsequent 8 weeks. Fever and buttock pain resolved within a few days, and the patient was again able to bear weight after 2 weeks. After I month of therapy. the patient was asymptomatic. the ESR was 7 mm/h, and the WBC count was normal. A pelvic radiograph taken at the end of therapy showed marked sclerosis of the right sacroiliac joint. Anaerobic infection of bones and joints is rare and represents < I %of all cases of osteomyelitis [2]. Only a few cases of anaerobic pyogenic sacroiliitis have been reported [3-5]. To our knowledge, this is the first report of septic sacroiliitis due to V. parvula.
176
Correspondence
Table 1. jJ-Hemolytic streptococci with Lancefield group C or G antigenic determinants. jJ-Hemolytic streptococci Large-colony formers
Currently proposed nomenclature
S dvsgalactiae' (CG) S equi (C) S. equi subspecies zooepideniicus
Former nomenclature
Acetoin production*
-s. equisimilis" (C)
S. equi (C) "S zooepidemicus"
(C)
(C)
CID 1992; 15 (July)
these species is based on phenotypic traits not assayed in currently available kits for streptococcal identification. Since taxonomic studies also suggest that human strains of large-colony-forming group C and G streptococci are related at the species level, perhaps these organisms should be considered together when assessments of the clinical impact of different tJ-hemolytic streptococci are made. Although keeping up with changes in taxonomy and nomenclature is usually regarded by physicians and clinical microbiologists as a cruel and unusually punishing part of their jobs, accurate classification allows for a clear assessment of the differing pathogenic potentials of microorganisms encountered in clinical specimens.
S. canisi (G) Small-colony formers
S. anginosus
S. anginosus (CG) "S. ntilleri" (CG)
NOTE. Letters in parentheses refer to Lancefield group C or G antigenic determinants. * Determined by the Voges-Proskauer test. t Name originally given to a-hemolytic group C streptococci isolated from animals. It currently applies to large-colony-forming groups C and G streptococci normally isolated from human sources. t The proposed name for large-colony-forming jJ-hemolytic group G streptococci isolated from animals. This name was formerly (and unofficially) used to describe group G strains isolated from dogs.
pal features of both the large- and small-colony-forming group C and G tJ-hemolytic streptococci are summarized in table 1. The taxonomy and classification of tJ-hemolytic streptococci are still works in progress, and no doubt many more changes will occur before a universally agreed-upon scheme is advanced. Simple procedures like the Voges-Proskauer test (for acetoin production from glucose) are essential for confirming the difference between large- and small-colony-forming streptococci of groups C and G. There are, however, no simple commercially available methods for accurate identification of the newly described species within the "S. milleri" group. The division of strains into
Nasal Tuberculosis: Two Cases in Elderly Patients SIR-To the best of our knowledge, only two case reports of nasopharyngeal tuberculosis have been published since ·1950 [1, 2]. We describe two elderly people who presented with nasal obstruction and for whom tuberculosis was initially misdiagnosed. In February 1989, a 74-year-old woman without any relevant medical history consulted an otolaryngologist because of recent nasal obstruction. Physical examination revealed a granular lesion located on the right side of the nasal septum. Microscopic Correspondence: Dr. Armelle Gentric, Clinique Medicale Harvier, C.H.U.A. Morvan, B.P. 624. 29609 Brest Cedex, France.
Clinical Infectious Diseases 1992;15:176-7 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1501-0031$02.00
Kathryn L. Ruoff
+
Microbiology Laboratories, The Massachusetts General Hospital, Boston, Massachusetts
References
J. Vance OW Jr. Group C streptococci: "Streptococcus equisimilis" or Streptococcus anginosusl Clin Infect Dis 1992; 14:616. 2. Bradley SF, Gordon JJ, Baumgartner DO, Marasco WA, Kauffman CA. Group C streptococcal bacteremia: analysis of88 cases. Rev Infect Dis 1991; 13:270-80. 3. Farrow JAE. Collins MD. Taxonomic studies on streptococci ofserological groups C. G and L and possibly related taxa. System Appl MicrobioI 1984;5:483-93. 4. Devriese LA. Hommez J, Kilpper-Balz R, Schleiffer K-H. Streptococcus canis sp. nov.: a species of group G streptococci from animals. Int J Syst Bacteriol 1986;36:422-5. 5. Whiley RA. Beighton D. Emended descriptions and recognition of Streptococcus constellatus. Streptococcus intermedius. and Streptococcus anginosus as distinct species. Int J Syst Bacteriol 1991 ;41: 1-5. 6. Coykendall AL, Wesbecher PM, Gustafson KB. "Streptococcus milleri" Streptococcus consteilatus. and Streptococcus intermedius are later synonyms of Streptococcus anginosus. Int J Syst BacterioI1987;37:222-8. 7. Whiley RA, Fraser H. Hardie JM, Beighton D. Phenotypic differentiation of Streptococcus intermedius. Streptococcus constellatus, and Streptococcus anginosus strains within the "Streptococcus tnilleri group." J Clin Microbiol 1990;28: 1497-50 J.
examination of the biopsy material showed a lymphocytic infiltrate containing giant-cell histiocytic granulomas without necrosis. Stains of the material for acid-fast bacilli were negative. A diagnosis of tuberculosis was considered. A chest radiograph showed no abnormalities. Fiberoptic bronchoscopy was performed, and culture and Ziehl-Neelsen staining of bronchial washings were negative for acid-fast bacilli. The patient was in good condition and had no biological inflammatory syndrome; the diagnosis of tuberculosis was not retained. Local treatment was undertaken. In December 1991, she was admitted to our unit because of worsening of her nasal discomfort. The lesion was macroscopically more significant than 2 years before, and histologic examination revealed necrosis of some granulomas. Results of staining for acid-fast bacilli remained negative. A chest roentgenogram showed bilateral apical scarring, and new sputum cultures yielded Mycobacterium tuberculosis. The patient was treated with isoniazid, rifampicin, and pyrazinamide.
Downloaded from http://cid.oxfordjournals.org/ at Sheffield University on September 15, 2015
(CG) S. constellatus (C G)
175
Correspondence
Pyogenic Sacroiliitis Due to Veillonella parvula
J. Pouchot, Ph. Vinceneux, C. Michon, A. Mathieu, and Y. Boussougant Service de Medecine Interne V. Universite Paris VII. HOpita! Louis Mourier. Colombes. France
References 1. Singh N. Yu VL. Osteomyelitis due to Veillonella parvula: case report and review. Clin Infect Dis 1992;14:361-3. 2. Raff MJ. Melo Jc. Anaerobic osteomyelitis. Medicine (Baltimore)
1978:57:83-103. 3. Ziment I. Davis A. Finegold SM. Joint infection by anaerobic bacteria: a case report and review of the literature. Arthritis Rheum
Correspondence: Dr. Jacques Pouchot, Service de Medecine Interne V, Hopital Louis Mourier, 178 rue des Renouillers, 9270 I Colombes Cedex, France.
Clinical Infectious Diseases 1992;15:175 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1501-0029$02.00
Group C Streptococci: A Current View SIR-A recent letter by Vance [l] addressing the review of group C streptococcal bacteremia by Bradley et al. [2] emphasized the need for physiological testing in addition to serological grouping for accurate identification of group C streptococci. This concept is certainly sound, but newer taxonomic information has enlarged the topic of group C streptococci to include group G streptococci and the recent reclassification of"Streptococcus milled" organisms. ,a-Hemolytic streptococci can usually be characterized as forming large or small colonies, with the large-colony formers comprising virulent group A, C, and G strains and the smallcolony formers (which may exhibit group A, C, G, or F anti-
Correspondence: Dr. Kathryn L. Ruoff. Microbiology Laboratories. Massachusetts General Hospital. Boston, Massachusetts 02114.
Clinical Infectious Diseases 1992;15:175-6 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/150[-0030$02.00
1969;12:627-35. 4. Longoria RR. Carpenter JL. Anaerobic pyogenic sacroiliitis. South Med J 1983;76:649-51. 5. Rosenberg D. Baskies AM. Deckers PJ. Leiter BE, Ordia Jl, Yablon IG. Pyogenic sacroiliitis. An absolute indication for computerized tomographic scanning. Clin Orthop 1984; 184:128-32.
gens) representing members of the "S. mil/err' group. The taxonomic study of Farrow and Collins [3] demonstrated that large-colony-forming group G isolates from humans and group C strains resembling "Streptococcus equisimilis" are physiologically and genetically similar enough to be included in the same species. These investigators proposed the name Streptococcus dysgalactiae (formerly used for a-hemolytic group C strains isolated from animals) for these organisms. Among strains commonly isolated from animals. those resembling "Streptococcus zooepidemicus" were considered to form a subspecies of Streptococcus equi. Devriese et al. [4] subsequently proposed Streptococcus canis as the official name for large-colony-forming ,a-hemolytic group G streptococci isolated from animals. Meanwhile, Whiley and Beighton [5] presented taxonomic evidence that the "S. millen', group organisms, formerly included in a single species (Streptococcus anginosus) by Coykendall and associates [6]. really consist of three separate species: Streptococcus constellatus, Streptococcus intermedius. and S. anginosus. According to their emended species descriptions [5] and other data provided by Whiley et al. [7], it seems that smallcolony-forming group C or G ,a-hemolytic strains could be classified as either S. anginosus or S. constellatus. Some of the princi-
Downloaded from http://cid.oxfordjournals.org/ at Sheffield University on September 15, 2015
SIR-We read with interest the recent report and review by Singh and Yu [I] on osteomyelitis due to Veillonella parvula. They emphasized the rarity of bone infection due to anaerobic bacteria. We would like to report a unique case of septic sacroiliitis due to V. parvula. A 33-year-old alcoholic man presented with an 8-day history of excruciating low back and right buttock pain associated with a fever of 38.5°C. The patient was unable to bear weight; physical examination revealed tenderness over the sacroiliac joint, and the conventional maneuvers to stress the sacroiliac joint were painful. There was no palpable abscess, and the remainder of the physical examination was unremarkable. An initial pelvic radiograph was considered normal. High clinical suspicion of infectious sacroiliitis led to the performance of a bone scan, which revealed increased uptake over the right sacroiliac joint. The computed tomographic examination showed joint space widening with bony erosions of both iliac and sacral joint margins. There was no evidence of abscess in the surrounding soft tissues. The erythrocyte sedimentation rate (ESR) was 101 mm/ h, and the white blood cell (WBC) count was 11,500/mm 3 • Needle biopsy of the right sacroiliac joint was performed, which disclosed evidence of infectious sacroiliitis with inflammatory changes associated with numerous altered polymorphonuclear neutrophils. Unfortunately, the biopsy was performed after the patient had received 6 million units of penicillin G, and culture
of bone samples remained sterile. Three blood cultures yielded V. parvula that was susceptible to penicillins, cephalosporins, clindarnycin, and chloramphenicol. Therapy consisted of bed rest and administration of intravenous penicillin G (24 million units per day) for the first 2 weeks. Oral amoxicillin (3 g per day) was administered for the subsequent 8 weeks. Fever and buttock pain resolved within a few days, and the patient was again able to bear weight after 2 weeks. After I month of therapy. the patient was asymptomatic. the ESR was 7 mm/h, and the WBC count was normal. A pelvic radiograph taken at the end of therapy showed marked sclerosis of the right sacroiliac joint. Anaerobic infection of bones and joints is rare and represents < I %of all cases of osteomyelitis [2]. Only a few cases of anaerobic pyogenic sacroiliitis have been reported [3-5]. To our knowledge, this is the first report of septic sacroiliitis due to V. parvula.
176
Correspondence
Table 1. jJ-Hemolytic streptococci with Lancefield group C or G antigenic determinants. jJ-Hemolytic streptococci Large-colony formers
Currently proposed nomenclature
S dvsgalactiae' (CG) S equi (C) S. equi subspecies zooepideniicus
Former nomenclature
Acetoin production*
-s. equisimilis" (C)
S. equi (C) "S zooepidemicus"
(C)
(C)
CID 1992; 15 (July)
these species is based on phenotypic traits not assayed in currently available kits for streptococcal identification. Since taxonomic studies also suggest that human strains of large-colony-forming group C and G streptococci are related at the species level, perhaps these organisms should be considered together when assessments of the clinical impact of different tJ-hemolytic streptococci are made. Although keeping up with changes in taxonomy and nomenclature is usually regarded by physicians and clinical microbiologists as a cruel and unusually punishing part of their jobs, accurate classification allows for a clear assessment of the differing pathogenic potentials of microorganisms encountered in clinical specimens.
S. canisi (G) Small-colony formers
S. anginosus
S. anginosus (CG) "S. ntilleri" (CG)
NOTE. Letters in parentheses refer to Lancefield group C or G antigenic determinants. * Determined by the Voges-Proskauer test. t Name originally given to a-hemolytic group C streptococci isolated from animals. It currently applies to large-colony-forming groups C and G streptococci normally isolated from human sources. t The proposed name for large-colony-forming jJ-hemolytic group G streptococci isolated from animals. This name was formerly (and unofficially) used to describe group G strains isolated from dogs.
pal features of both the large- and small-colony-forming group C and G tJ-hemolytic streptococci are summarized in table 1. The taxonomy and classification of tJ-hemolytic streptococci are still works in progress, and no doubt many more changes will occur before a universally agreed-upon scheme is advanced. Simple procedures like the Voges-Proskauer test (for acetoin production from glucose) are essential for confirming the difference between large- and small-colony-forming streptococci of groups C and G. There are, however, no simple commercially available methods for accurate identification of the newly described species within the "S. milleri" group. The division of strains into
Nasal Tuberculosis: Two Cases in Elderly Patients SIR-To the best of our knowledge, only two case reports of nasopharyngeal tuberculosis have been published since ·1950 [1, 2]. We describe two elderly people who presented with nasal obstruction and for whom tuberculosis was initially misdiagnosed. In February 1989, a 74-year-old woman without any relevant medical history consulted an otolaryngologist because of recent nasal obstruction. Physical examination revealed a granular lesion located on the right side of the nasal septum. Microscopic Correspondence: Dr. Armelle Gentric, Clinique Medicale Harvier, C.H.U.A. Morvan, B.P. 624. 29609 Brest Cedex, France.
Clinical Infectious Diseases 1992;15:176-7 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1501-0031$02.00
Kathryn L. Ruoff
+
Microbiology Laboratories, The Massachusetts General Hospital, Boston, Massachusetts
References
J. Vance OW Jr. Group C streptococci: "Streptococcus equisimilis" or Streptococcus anginosusl Clin Infect Dis 1992; 14:616. 2. Bradley SF, Gordon JJ, Baumgartner DO, Marasco WA, Kauffman CA. Group C streptococcal bacteremia: analysis of88 cases. Rev Infect Dis 1991; 13:270-80. 3. Farrow JAE. Collins MD. Taxonomic studies on streptococci ofserological groups C. G and L and possibly related taxa. System Appl MicrobioI 1984;5:483-93. 4. Devriese LA. Hommez J, Kilpper-Balz R, Schleiffer K-H. Streptococcus canis sp. nov.: a species of group G streptococci from animals. Int J Syst Bacteriol 1986;36:422-5. 5. Whiley RA. Beighton D. Emended descriptions and recognition of Streptococcus constellatus. Streptococcus intermedius. and Streptococcus anginosus as distinct species. Int J Syst Bacteriol 1991 ;41: 1-5. 6. Coykendall AL, Wesbecher PM, Gustafson KB. "Streptococcus milleri" Streptococcus consteilatus. and Streptococcus intermedius are later synonyms of Streptococcus anginosus. Int J Syst BacterioI1987;37:222-8. 7. Whiley RA, Fraser H. Hardie JM, Beighton D. Phenotypic differentiation of Streptococcus intermedius. Streptococcus constellatus, and Streptococcus anginosus strains within the "Streptococcus tnilleri group." J Clin Microbiol 1990;28: 1497-50 J.
examination of the biopsy material showed a lymphocytic infiltrate containing giant-cell histiocytic granulomas without necrosis. Stains of the material for acid-fast bacilli were negative. A diagnosis of tuberculosis was considered. A chest radiograph showed no abnormalities. Fiberoptic bronchoscopy was performed, and culture and Ziehl-Neelsen staining of bronchial washings were negative for acid-fast bacilli. The patient was in good condition and had no biological inflammatory syndrome; the diagnosis of tuberculosis was not retained. Local treatment was undertaken. In December 1991, she was admitted to our unit because of worsening of her nasal discomfort. The lesion was macroscopically more significant than 2 years before, and histologic examination revealed necrosis of some granulomas. Results of staining for acid-fast bacilli remained negative. A chest roentgenogram showed bilateral apical scarring, and new sputum cultures yielded Mycobacterium tuberculosis. The patient was treated with isoniazid, rifampicin, and pyrazinamide.
Downloaded from http://cid.oxfordjournals.org/ at Sheffield University on September 15, 2015
(CG) S. constellatus (C G)
